Abstract: Objective　To study the effect of TCM management of diabetes on type 2 diabetic patients by the team mainly consisting of general practitioners.Methods　We enrolled 269 type 2 diabetic patients from January to June 2017 who were under management of Wudong Team Guyi Community Neighbourhood Committee of Tianlin Street Community Health Center located in Shanghai's Xuhui District.They received 1-year TCM management of diabetes from Wudong Team mainly consisting of general practitioners.The outcome was evaluated from the following 5 aspects at the end of management：（1） incidence of complications；（2） survey results of Knowledge，Attitude and Practice of TCM Prevention and Treatment of Diabetes（KAP），Chinese version of Diabetes Management Self-efficacy Scale （C-DMSES），Chinese version of Problem Areas in Diabetes Scale（PAID）；（3） plasma glucose control status assessed in accordance with fasting plasma glucose（FPG），2-hour postprandial blood glucose（2 hPG） and glycosylated haemoglobin（HbA1c）；（4） degree of renal impairment〔identified based on urine albumin/creatinine ratio （urine ACR），renal impairment was defined as the urine ACR≥30 mg/g〕；（5） mean annual and daily costs.Results　At the end of intervention，the patients showed significantly higher scores of KAP，C-DMSES and PAID，much lower FPG，2 hPG and HbA1c levels，obviously decreased mean annual and daily costs（P<0.05），although the incidence of cerebrovascular disease，cardiovascular disease，peripheral vascular disease，retinopathy，diabetic nephropathy，neuropathy，cataract，diabetic foot and diabetic ketosis，urine ACR，and prevalence of positive urine ACR changed little（P>0.05） compared with baseline.Conclusion　For type 2 diabetic patients，TCM management of diabetes by the team mainly consisting of general practitioners helps control or stabilize the blood glucose，decrease the medical costs.

Key words: Diabetes mellitus, type 2；General practitioners；Administrations （TCM ＆ TCD）；Service process

摘要： 目的　研究以全科医生为主体的糖尿病中医药健康管理服务流程对2型糖尿病患者的影响。方法　2017年1—6月，以上海市徐汇区田林街道社区卫生服务中心吴东团队古宜社区居民委员会纳入管理的269例2型糖尿病患者为研究对象。按照以全科医生为主体的糖尿病中医药健康管理服务流程进行慢性病管理。对患者干预1年，于干预前后进行指标评价：（1）并发症评价；（2）量表评价：糖尿病中医防治知信行量表积分（KAP）、糖尿病管理自我效能量表积分（C-DMSES）、糖尿病问题量表积分（PAID）；（3）血糖评价：测定空腹血糖（FPG）、餐后2 h血糖（2 hPG）、糖化血红蛋白；（4）糖尿病肾损害评价：测定尿微量清蛋白/尿肌酐比值（尿ACR），尿ACR≥30 mg/g定义为阳性；（5）医疗费用：年医疗费用及日均费用。结果　干预前后，患者脑血管病变、心血管病变、外周血管病变、视网膜病变、糖尿病肾病、神经病变、白内障、糖尿病足、糖尿病酮症发生率比较，差异均无统计学意义（P>0.05）。干预后，患者KAP、C-DMSES、PAID评分均高于干预前（P<0.05）。干预后，患者FPG、2 hPG、糖化血红蛋白水平均低于干预前（P<0.05）。干预前后，患者尿ACR、尿ACR阳性率比较，差异均无统计学意义（P>0.05）。干预后，患者年医疗费用及日均费用均低于干预前（P<0.05）。结论　以全科医生为主体的糖尿病中医药健康管理服务流程可以使2型糖尿病患者更好地控制血糖，利于血糖稳定，降低医疗费用。

关键词: 糖尿病, 2型；全科医生；中医药管理；服务流程